Dynamic positions in birth: a fresh look at how women's bodies work in labour by Margaret Jowitt

One of the main paradoxes of birth in many high income countries is that everyone knows that upright is better and all the clinical guidelines recommend encouraging women to adopt upright positions. But most women in the UK will give birth in an obstetric unit having watched the television programme One Born Every Minute and will find themselves on a bed. Margaret Jowitt reports that the National Maternity Survey for England for 2013 (Care Quality Commission 2013) showed that while 23% of first-time mothers had an assisted vaginal delivery, which requires being delivered with legs in stirrups, as many as 48% of first time mothers report giving birth in this lithotomy position, implying that half the spontaneous births were conducted in the lithotomy position and most of the rest occurred on the bed. 19% of spontaneous births in all women took place with the mother's legs in stirrups while 85% of women giving birth vaginally did so in a bed and 8% gave birth in a birthing pool.

In answer to the question about why women get on the bed, Margaret Jowitt suggests that the dominant presence of a bed in a labour room is the first medical intervention (though one could argue that several other interventions are likely to have occurred before a woman gets onto a bed). She asks the reader to imagine sitting on the floor in consultation with their GP at the GP surgery to understand why women find it hard to resist getting onto a bed. (It also occurs to me that in a hospital room without a pool it may imply a small degree of privacy.) She also talks of the concept of 'protective steering', where women are persuaded to conform to hospital culture with its different priorities.

I enjoyed reading this collection of thoughts, history, present practice and recommendations about positions for labouring and giving birth.

After a short history of birth furniture through the ages, complete with charming illustrations dating from ancient times, Margaret Jowitt goes on to discuss the research evidence on maternal positions and describes the 'choreography of birth', showing how the common obstetric view understates the role of an active mother whose movements interact with those of the baby and play an important part in contributing to the optimum positioning of the baby. She gives her own suggestions about a possible birthing chair and concludes that women need education about their bodies, the physical and emotional support of a midwife and the right type of birth equipment to find for themselves the positions that will reduce their pain and let their bodies work efficiently and effectively. She argues that women may find these conditions in a birth centre, but she doesn't elaborate a great deal on this as hospitals are where most women give birth, with many being attended by doctors (40% - up from 24% in 1990) and so this is where change needs to happen.

Ghostbelly: a memoir by Elizabeth Heineman

Now that the topic of loss in childbearing has been well and truly opened up, it seems to be addressed in one of two ways. First are the saccharine, slightly patronising and purportedly reassuring materials. Their message is one of 'This is most unlikely to happen to you, but if it does - you'll get over it.' Second are the factual, research-based, more scholarly materials, whose message is 'This is most unlikely to happen, but if it does - this is what services are available.' Elizabeth (Lisa) Heineman's book falls into neither of these camps. Hers is a fierce, feisty, no punches pulled personal account of a baby being stillborn in the USA. The message underpinning her book is 'This is what happened to me and my much-wanted baby. It was hell and I had to work bloody hard to survive the experience.'

The ferocity of Lisa's writing is thrown into even sharper relief by the rib-tickling humour that she brings to otherwise heart-rending situations. One of these incidents is the encounter with an official who haplessly endeavours to restrict her contact with her stillborn baby to thirty minutes (pages 22-3).

Thus, the mercilessness of Lisa's message is not assuaged but actually aggravated by her humour. This means that my task as a reader was not an easy one. Reading at length about her convoluted personal and family relationships led me to question 'Why is all this detail of unlikely liaisons necessary?'' The answer eventually emerges in the form of needing to understand the context of the loss, in order to approach its meaning to all who are affected by the baby being stillborn. I also found that Lisa's gradually emerging decision to give birth at home was a challenge to me as a reader. Beginning as carrying an aura of fatefulness, the realisation eventually dawns that the birth constitutes a sword of Damocles hanging over Lisa, her partner and her baby. Her misgivings about her homebirth decision are revisited regularly and often throughout the book and seem to linger, suspended in their unresolved state.

In the same way as the homebirth decision seems to be presented as an accident waiting to happen, Lisa's plans for another pregnancy seem doomed. Just as a child peeks through her fingers at a disturbing programme or film, I found myself torn between cutting my losses and continuing to read.

This is quite unquestionably a book that needed to be written. At the same time as there seems to be an element of catharsis for Lisa, its publication fills a gaping hole in the literature on childbearing loss. Who should be reading it and when, though, are entirely different matters.

Nutrition in pregnancy and childbirth: food for thought edited by Lorna Davies and Ruth Deary

Although this is a reference book aimed at health professionals working in midwifery or public health, I would recommend it to women with an interest in how pregnant women eat and how that affects their babies and, importantly, themselves. When women are pregnant they are generally highly sensitive to what they will eat, drink, smoke - and often attuned to pressure from others. Sadly, advice to women from health professionals has been too often 'what not to eat', an unhelpful, often not well-evidenced, risk-based approach, and the response from a woman's immediate circle isn't always the positive, nourishing help that we might appreciate.

Part one, Healthy Eating and Nutrition in Childbirth, details current knowledge on nutritional needs in pregnancy succinctly and helpfully. Unfortunately, current knowledge may not be very adequate: for example, the current advice on folate suggests that 'it would be difficult for women to receive all of the folate that they need in order to achieve suitable levels of folate during pregnancy; therefore supplementation with the synthetic folic acid is recommended to women, ideally before they conceive'. This may well be the case but 40% of pregnancies are unplanned in the UK, and although voluntary fortification of food stuffs is allowed, the recommended dosage in the UK is half of that recommended in New Zealand, for example. It is tempting to conclude that we simply don't know enough to advise knowledgeably, and that research in this area is not attractive enough financially to improve our knowledge, so midwives and mothers are having to rely on incomplete information. Anne Mullen and her colleagues summarise the state of knowledge on macro and micro-nutrients, in a useful way, pointing out that in New Zealand a third of women are thought to be deficient in vitamin D, iodine deficiencies are common and it's thought that as many as 62% of pregnant vegetarian mothers, who are often young, suffer from a lack of vitamin B12.

Similarly Victoria Hall Moran points out in her chapter on nutritional needs for lactation that advice on alcohol intake during breastfeeding is vague. This is because there is little evidence for any outcomes at the low levels that most women will want to know about. She also points out that very little is known about birth spacing, breastfeeding and nutritional needs.

Part 2 looks at context and cultural issues: for example, what constitutes food in different cultural settings; the impact of breastfeeding on children's interest in a wider variety of tastes; caring for the significant number of women with eating disorders; vegetarian and vegan pregnancies; and working with young pregnant women. All of these issues are interesting and useful to women and midwives.

Obesity is an issue causing great difficulty for midwives and mothers. This book bravely asserts that there are structural causes, larger social patterns that shape the nutritional status of individual women, and factors far beyond their own food choices. Ruth Deery acknowledges a lack of knowledge among midwives and health professionals of the social, psychological and economic effects that influence obesity as well as personal wellbeing. Midwives must help women as individuals without 'victim blaming', via 'the midwifery stance of being with the woman', and respectfully listen. When asking potentially intrusive questions about a genuine concern, 'looking straight in the eye' will help women to be able to interpret the questions as supportive rather than policing. Dieticians Brady, Aphramor and Gingras recognise that nutritional advice given by midwives can be inconsistent and prescriptive. They expound a heartening alternative approach, the Health at Every Size perspective, which is respectful of and compassionate towards all bodies of any size.

Finally, Gill Rapley's chapter on baby-led weaning is something I would like everyone to read. She concludes that research strongly suggests that denying the very young the opportunity to make feeding choices has the potential to lead to serious consequences and that health professionals need to be wary of interfering in matters about which babies probably do know best.

There is much in this book that needs to be explored as we begin to recognise again the importance of 'proper' food for the long-term health of humanity.